Tag Archives: pay-for-performance

Survey says….

When Advanced Inpatient Medicine started at our Wilkes-Barre site in October of 2013, I saw a very dysfunctional facility that was essentially run by specialists and the primary care docs that consulted them frequently. There was no thought to the changing landscape from a fee for service mentality to a pay for performance one. Right before we started there, I met with the CEO & warned that if we did our job right, he would have many consultants beating down his door to complain about us. In fact, that is exactly what happened. We didn’t consult a pulmonologist for every simple pneumonia or cardiologist for every chest pain, so, as our service grew, some specialists got upset and considered us a threat to their livelihood. One went so far as to try to get us thrown out with literally fabricated stories about our performance. On the 2014 physician satisfaction survey, my fellow medical staff, especially the medical specialists, crucified us. They were very critical and talked about a lack of communication and expressed concerns about clinical quality of care. After all, as one cardiologist put it, “You can’t possibly take care of CHF without a cardiologist.” Yes, it was that bad. We had to work with the CMO & other staff to create a dashboard to show that our quality was better than the general primary care doctors, with a markedly lower length of stay with no corresponding increase in admission rates.
Fast forward a year later to the newly released annual physician satisfaction survey this week. Our group has had a tremendously large increase in our scores across the board. No longer does the medical staff seem suspicious that everything we do is part of some conspiracy to affect their livelihood. (Yes, there is always one who just won’t give up that idea!) We received much higher marks in the perception of quality of care, communication, etc. The bottom line is that we have now generally become accepted as a part of the medical staff that provides a quality role at that hospital. That is a very gratifying survey to read because it means that things are progressing right on schedule. Taking care of hospitalized patients is the easy part, and not a whole lot different from place to place. Changing a culture requires patience & the ability to communicate openly & realize that this is a gradual process. Bad habits have been allowed to fester for a generation. Yet, we are slowly putting in system & process improvements that are starting to create fundamental change. The resistant few are beginning to realize that pay for performance is coming whether they like it or not. Those that refuse to embrace it will be left without a hospital to work at. Truthfully, that’s fine with me because I believe that our hospitalist team will be able to provide excellent care of those patients.
AIM continues to grow by hiring staff that embrace the two pronged challenge of patient care and improving the system. Are you one of those looking to truly make a difference? We have added several more sites and are looking for some talented providers that have that same mindset. Time to jump on board!

A Singular Honor

Happy New Year! Today, I found out that I would be the 4th ever recipient of the Certified Leader in Hospitalist Medicine designation. To be recognized as such, one has to complete three Leadership courses and a research project. The Leadership courses that are offered through the Society of Hospitalist Medicine (SHM) have had an enormous impact on my ability to lead my program. Courses cover leadership, finance, hospital finances, conflict resolution, negotiation, and many, many more. If anyone is interested in taking a leadership role in hospitalist medicine, these courses are a must. The research project must be approved by a review board and it is a very detailed process.
My project was to show that we can perform several interventions in a rural setting to decrease readmissions for four key diagnoses: CHF, MI, COPD exacerbations, and pneumonia. I chose this for our rural site at Wayne Memorial Hospital because I couldn’t find a single study regarding readmissions that was performed in a rural site, and thought that perhaps there would be other factors that affect readmission rates here versus an urban setting. As it turns out, we used four interventions: hiring four discharge coordinators to do bedside teaching & arrange follow-ups, etc., having the pharmacist perform medication reconciliation at the bedside prior to discharge, a home health visit on the 3rd day after discharge for everyone, and follow-up phone calls from both a pharmacist & discharge coordinator. The results were better than anticipated. Readmission rates fell over 34% over the one year study period, with CHF being the main diagnosis showing the statistical significance. As it turns out, being on ten or more meds at discharge was significant, and the home health intervention was also significant. No other variable turned out to make a difference, although I suspect having the coordinators make the follow-up appointments and phone calls had a large contribution to the decrease, although it couldn’t be shown statistically. As a result, we changed our approach to discharges and continued and expanded the coordinator role long-term. The bottom line is that we showed that research studies like this can be performed in a rural setting successfully, and I am very proud of this accomplishment. For the full details & discussion, look for the report soon on the SHM web site & eventually in the hospitalist literature where we hope to publish the entire project.
Having achieved this honor solidifies my place, and, more importantly, my program’s place as a leader in hospitalist medicine. When I started this company in 2006, I approached this with the idea that we can do things differently. I wanted to make a difference and become a leader for change. I wanted to make hospitals more efficient, safer, and of higher quality. Many hospitalist programs and companies are interested in profit margins and growth. I am as interested in profit as anyone, but that is not my focus at all. I fit well with the SHM because their goals mirror my own and they don’t provide just lip service. Their goal is to train the leaders of tomorrow who will help us transition from a fee-for-service mentality to a pay for performance model. I am proud to be a part of that change and perhaps a leader of this change by my example. Advanced Inpatient Medicine has adopted this goal which reflects my philosophy. If you are interested in making a difference & not just ‘working’ as a hospitalist, then come on and jump on board and be a part of something special. We are growing & can use the help.

An overview at one year

One year at our newest site in Wilkes-Barre has come and gone and with it, a lot of changes. Starting fresh at a facility that simply hasn’t been progressive in the transition from fee-for-service to pay-for-performance has not been easy. Taking a facility where specialists run the show and transitioning to hospitalists who can manage in a more cost effective and efficient manner was initially met with resistance by many specialists. Perhaps we came on too strong initially, since, after all, this whole hospitalist thing came as a complete culture shock to them. Fortunately, we were able to show an ever increasing split between our data metrics versus the private physician community. That included length of stay, case mix index, and others. Those differences add up to millions of dollars to the hospital when extrapolated over time, and that’s why the administration has been totally supportive of trying to promote the growth of our program.
It isn’t an easy task. What do you say to the worst offenders in the hospital, the ones with the extra-long lengths of stay who waste resources and cost the hospital money? “Well doctor, we want you to give your patients to the hospitalists because we can save money and they do a better job”. Not exactly a way to endear yourself to the medical staff. Economics does speak volumes these days, though, and the hospital does indeed want us to grow because we simply do a better job of inpatient care. By better, they mean more efficient and more cost effective. When we do a better job, people get out of the hospital faster & that saves the hospital lots of money. Larger than that, I think that the higher quality issue is far more important. Hospitalists are supposed to be able to provide care that is better, as in up to date, accurate and effective care. Our group meets every month and has a journal club. We review the latest literature & keep up with the latest standards of care. We work hard to provide the highest quality of care possible and all of our staff are always encouraged to keep up with the latest news in the medical literature. That’s the ‘better’ type of care that I think about. Interesting though, most data suggest that higher quality of care is actually more cost effective as well, so being a top notch doctor usually means being a more cost effective one as well. It has been gratifying that this has been noticed and the administration has given us their full support to continue to expand.
Year two will bring a different set of challenges as we continue to grow. We want to start to put our stamp on the inpatient process and really start to transform things. We have talked about improving patient flow from the ED, geographic rounding, better handoffs, team rounds with nursing, and a host of changes that will result in better communication and better patient care. If we do that, the ‘better’ care becomes more cost-effective care, and the entire hospital benefits in addition to the patients. That’s the brass ring of being a hospitalist. We love the challenge of getting there.

Whoever said change is easy wasn’t talking about hospitals!

The harsh reality of starting a new hospitalist program is that there are those in that hospital that will embrace it and those that just won’t, no matter what. People fear change, even if it is to their benefit. The old guard of specialists and surgeons at our newest site is a perfect example of how tricky new start-up programs are.

    AIM took over its latest site in October of 2013. (Which is why I haven’t had much time to blog!) It became apparent very quickly that not everyone was happy to see us. After a few weeks, we figured out why. The specialists and surgeons dominated the hospital from top to bottom, and they were completely out of control. Consultants consult multiple other consultants, surgeons count the number of consults our team writes for them versus other docs in the same specialty, and make sure that they exact every nickel out of a patient regardless of length of stay or any quality metrics. It borders on unethical. Pulmonologists argued that our hospitalists weren’t qualified to provide ventilator management, even though it was part of our credentials. They didn’t argue because of patient safety, but purely because of economics. Every aspect of this inpatient care facility was doctor driven, with no regard for input from other personnel, including, in many cases, the patient. So, here comes our new hospitalist group into the fire. We started off by creating a multidisciplinary team to increase efficiency and communication between departments. We pushed administration to support us as we fought the cardiology groups to start performing stress tests and echoes on weekends to improve the dismal length of stay at the facility. (They were contracted to do so, but it had never been enforced.) We worked with radiology to be able to obtain MRIs on weekends as well. We knew Rome wasn’t created in a day, but we have begun to make inroads. Fortunately, administration realized the cost savings potential and has been backing us soundly since day one.

      On and on it went, seemingly every few days receiving a complaint or pushback from someone who was only interested in their own bottom line. It demonstrated the sad state of affairs that is much of the fee-for-service landscape that many cling to since they know how to take full financial advantage. When I extrapolate what is going on here nationally, it is no wonder there is a health care crisis! Pay-for-performance means accountability. When we bring up national measures like the Choosing Wisely campaign, it is intended to stop waste. The amount of waste going on at this one facility alone shows the problem on a frightening scale. Absolute power corrupts absolutely, right? Well, physicians in this facility have too much power. We need to create a patient-centric, TEAM approach to health care. That is the only way to create the safest, highest-quality, and most cost-effective hospital environment. So many are still trying to cling to the ‘good ol’ days’, when doctors could seemingly do whatever they wanted. Well, our team embraces the challenge of helping to change from a fee-for-service to a pay-for-performance environment. We aren’t afraid to partner with nurses, case managers, and patient educators. In fact, we are trying to bring them into our patient care model. That’s why we’ve been successful & why AIM is growing in size and reputation. It also doesn’t hurt that this model saves hospitals enormous amounts of money in the process. That’s why we want hospitalists on our team who can work as total team players. They can take great care of a single patient at the bedside, but also help to improve the entire system and process from admission to discharge.

    Changing a hospital landscape that is so uninterested in a progressive model of team-based health care that is cost-effective and of the highest quality is an enormous challenge. AIM embraces that challenge. It is very rewarding to see the buy-in from nurses and other ancillary personnel that are now being asked their opinions on patient care. Now, all we need to do is get the physicians, especially the specialists and surgeons, to start practicing medicine like they care about something other than their own bottom line. With time, they’ll come around. Guess what? If they don’t, the train isn’t waiting for them, folks. This is the way of medicine in 2014. Guess what else? It’s a better way.

Reducing readmissions…oops!

     On April 15th, AIM just wrapped up one of its many QI projects, this one looking at decreasing readmission rates for four major diagnoses (MI, CHF, COPD, & pneumonia) through 4 specific interventions. It was a great project, involving many people over multiple disciplines. We added staff to provide more in depth discharge planning at the bedside. The pharmacists were involved making phone calls after discharge to go over med issues & also did med rec prior to discharge. Home health visits for every patient enrolled in the project also took place. So far, it looks like we will have reduced the rates of readmissions for CHF, MI, pneumonia, & COPD by about 25-30%!

    Here’s the rub: we didn’t do our hospital any favors & in fact, cost them revenue. The ‘problem’ was that our baseline readmission rates were not excessive, around the national average of 18% or so. We were never going to be hit with readmission penalties. What we did, basically, is cost our hospital business. So, was it the right thing to do? I don’t think there is anyone who wouldn’t agree that this project & these interventions were very good things to be doing. This is a prime example of just how difficult the transition from fee-for-service to pay-for-performance will be. Hospitals are not going to embrace these changes if it hurts the bottom line, no matter how much better it is for patient care. ACO’s & other programs are looking at improving the overall health of the population. In all of these models, the hospital is the cost center and the area to take the biggest hits. As a hospitalist, I have been thinking about the somewhat sad realization that if we succeed in these endeavors, then the need for hospitalists will diminish considerably. All for the greater good? Maybe. Then again, we are talking about government programs here. At the rate our government moves, I will be long retired before health care ever becomes that efficient. I hope we get there, though….eventually.